Strategies for reducing blood transfusions in hepatic resection

Prognostic significance of preoperative blood transfusion in stomach cancer

Purpose

We did a retrospective study to understand the prognostic effects of preoperative blood transfusions in stomach cancer surgery.

Materials and Methods

Data for 1,360 patients who underwent gastrectomy for stomach cancer between 2001 and 2009 were retrospectively reviewed. We analyzed factors that affect preoperative transfusion and clinicopathologic features. We also analyzed 5-year and overall survival rates of the transfusion and non transfusion subgroups.

Results

Sixty patients (4.4%) required blood transfusion within the preoperative period. The transfused group included patients who took aspirin or clopidogrel (P<0.001), with more advanced T stages (P<0.001), with more advanced nodal metastasis (P=0.00), and with more advanced stages (P=0.00) than the non transfusion group. On multivariate analysis, preoperative transfusion was a statistically significant negative influence on 5-year survival and overall survival rates (58.2% vs 79.9% (P=0.00), 58.2% vs 76.8% (P=0.00)). Applying Cox-regression analyses, blood transfusion did appear to have an effect on prognosis and on 5-year and overall survival rates.

Conclusions

We found a direct negative relation between preoperative transfusion and long term prognosis in patients receiving gastric cancer surgery.

Factors influencing perioperative blood transfusions in patients with gastrointestinal cancer

BACKGROUND

Patients undergoing major cancer resections often receive blood transfusions (TFs). Preoperative erythropoietin (EPO) offers the rationale to reduce TFs and related morbidity.

METHODS

Perioperative TF information was collected prospectively in a single surgeon practice over 5 years.

RESULTS

Three hundred forty-four patients underwent a major procedure, including pancreatic (n = 130, 38%), hepatobiliary (n = 87, 25%), gastroesophageal (n = 69, 20%), and other operations (n = 58, 17%). Median estimated blood loss (EBL) was 375 mL. PRBC TFs were given in 83 cases (24%), at a median of 2 units [1-16]. TF frequency and EBL did not differ between diagnoses. Multivariate TF associations existed for Hgb (P < 0.0001, OR 0.335), EBL (P < 0.0001, OR 1.007), serum Cl (P = 0.004, OR 1.25), serum Na (P = 0.02, OR 0.810), and age (P = 0.04, OR 1.033). TFs (versus no TFs) were linked to major complications (43 versus 20%, P = 0.0002), mortality (12% versus 3%, P = 0.001), and increased LOS (9 versus 7 days, P < 0.0001). A potential benefit for preoperative EPO to avoid TFs could be derived for only 31 patients (9%).

CONCLUSIONS

In this low TF rate of 24% for major visceral resections, few preoperative parameters are able to identify subgroups at risk for TFs aside from blood counts. Our data would not support generalized preoperative EPO administration.

Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion

There is evidence to suggest that there exists considerable variation in red blood cell (RBC) transfusion practices, especially in the surgical specialties. This is in large part related to difficulties in defining specific transfusion threshold criteria, given that there is no minimum acceptable hemoglobin threshold concentration and there is variability in assigning importance to patient factors. The purpose of this study is to identify patient-related factors that might be associated with the need for allogeneic RBC transfusion in surgical patients. We systematically identified, selected, and reviewed all observational or interventional studies describing patient-specific or related variables associated with the need for allogeneic RBC transfusion in the surgical patient population. We also evaluated the methodological characteristics of the individual studies. Sixty-two studies met our inclusion criteria and were analyzed for this review. Most of these studies were conducted in patients undergoing cardiac surgery (n = 30) and orthopedic surgery (n = 16). Decreased preoperative red cell reserve was most frequently associated with RBC transfusions, being identified as a significant variable in 46 studies. The other factors commonly associated with transfusion were advancing age (n = 28), female gender (n = 21), and small body size (n = 14). Only 2 studies attempted to prospectively validate a predictive model for RBC transfusion based on the variables identified. This systematic review shows that preoperative anemia, advancing age, female gender, and small body size are often associated with perioperative allogeneic RBC transfusion. However, the retrospective nature of most of the studies and the small sample sizes make it difficult to formulate a clinically useful prediction rules regarding allogeneic RBC transfusion. Ongoing research in designing large prospective cohort studies evaluating transfusion patterns are needed to further elucidate how patient characteristics impact the transfusion threshold.

One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery

A technique of hepatic resection is described and the results of 150 resections are reviewed. Hepatic transection was performed, under intermittent portal inflow occlusion, using ultrasonic aspiration to skeletonize portal branches and venous tributaries. Control of venous haemorrhage during resection was optimized by argon beam coagulation and lowering central venous pressure to between 0 and 4 cmH2O by extradural blockade and systemic nitroglycerine infusion. One patient with jaundice died in hospital, giving a mortality rate of 0.7 per cent. There were no deaths in patients without jaundice and cirrhosis. Fifteen patients (10.0 per cent) had significant complications, nine medical and six surgical, including three bile leaks (2.0 per cent). Mean blood loss was 814 ml for the whole study but only 434 ml in the last 4 years. During this latter period mean blood transfusion in hospital was 0.5 units and mean postoperative haemoglobin value fell by 0.7 g per 100 ml. Hepatic resection can be performed with the same degree of confidence and similar low morbidity as any other major surgical procedure.

Hepatectomy with an ultrasonic dissector for hepatocellular carcinoma

This study compared the results of hepatectomy for hepatocellular carcinoma (HCC) using an ultrasonic dissector with those of a combination of the crushing clamp and finger fracture techniques. The crushing clamp and finger fracture method was used from 1989 to 1992 in 96 patients (group 1) and the ultrasonic dissector from 1993 to 1994 in 69 patients (group 2). Data from these two sets of patients were collected prospectively. The groups were comparable in terms of preoperative liver function, tumour size and stage, and the incidence of cirrhosis. Major hepatectomy was performed in 69 patients (72 per cent) of group 1 and in 52 (75 per cent) of those in group 2. Use of the ultrasonic dissector resulted in lower mean (s.e.m.) blood loss (group 1 3.4(0.4) litres versus group 2 2.4(0.2) litres, P = 0.02), lower mean (s.e.m.) blood transfusion requirement (2.2(0.2) versus 1.2(0.2) litres, P = 0.001) and more patients not requiring blood transfusion (8 per cent of group 1 versus 32 per cent of group 2, P = 0.0001). Postoperative complications occurred in 45 patients (47 per cent) of group 1 and 19 (28 per cent) of those in group 2 (P = 0.012). There were no deaths in group 2 whereas the hospital mortality rate in group 1 was 16 of 96 (17 per cent) (P = 0.0004). A wider tumour-free resection margin (mean(s.e.m.) 1.2(0.1) versus 0.9(0.1) cm, P < 0.05) and lower serum bilirubin level throughout the postoperative period were also observed in group 2 patients. The ultrasonic dissector is better than the crushing clamp and finger fracture technique in hepatectomy for HCC.